Reinserting Tracheostomy Tube

<< RESPIRATORY

  • *THIS PROCEDURE IS TYPICALLY PERFORMED BY A REGISTERED NURSE
  • The use of this procedure guideline assumes that the registered nurse has the nursing education and skills to perform this task. This procedure guideline does not replace nursing clinical judgment.

Considerations:

  • The changing of a tracheostomy tube in the school setting should be considered an emergency situation
  • Any concern that the situation is potentially life-threatening requires the activation of the EMS/911 system while the procedure is being performed
  • When caring for a student who has a tracheostomy, the school nurse should always know the reason for the tracheostomy, the student’s underlying health conditions and whether the student needs the tracheostomy to breathe
  • The two most common emergency scenarios are:
    • accidental decannulization; and
    • tracheostomy tube obstruction unrelieved by reasonable suction attempts
  • There should always be a “GO BAG” (Emergency Travel Bag) accessible when completing any tracheostomy procedure.
  • If the student’s “GO BAG” contains a battery charged suction machine, the school nurse should check the battery charge level daily to ensure that it is fully charged.
  • The school nurses should establish a schedule to periodically check the “GO BAG” to ensure all necessary supplies are available, not expired, and are in working condition.
  • A shoulder roll is recommended to assist with the visualization and access to the tracheostomy site.
  • Obstruction can be caused by thick secretions/mucous plugging, foreign body, or airway granuloma tissue.
    • Airway granuloma tissue can persist to obstruct a new tracheostomy tube, resulting in the highest degree of medical emergency.

    Supplies:
    “GO BAG” (Emergency Travel Bag) Equipment:
    The essential equipment to be kept with the student at all times is as follows:

    • gloves
    • portable oxygen (if ordered)
    • appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube)
    • portable suction machine that can operate with battery or electricity
      • battery should have a full charge
    • sterile suction catheters
    • sterile saline vials
    • water-based lubricant
    • distilled or sterile water
    • 4×4 gauze
    • split gauze dressing (if student uses)
    • unscented and dye free soap
    • syringe, if needed for tracheostomy tube cuff
    • sterile water for cuffed trach filled with water
    • two spare tracheostomy tubes — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
    • obturator, if applicable
    • spare tracheostomy ties
    • blunt scissors
    • emergency phone numbers
    • pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation

    Additional Needed Supplies:

    • Stethoscope
    • Medical tape
    • Personal protective equipment
      • goggles
      • mask
      • gloves
    • Blanket role to place under the student’s shoulders
    • Accessible phone
    • Individualized Healthcare Plan
    • Healthcare provider’s order
    • Parent/Guardian authorization form
    Procedure Download
    Skill Competency Download

    Procedure:

    1. Activate EMS/911, if student is unresponsive
    2. Review healthcare provider’s order
    3. Ensure proper documentation of parent/guardian authorization to perform this procedure
    4. Reassure student
    5. Wash hands, if student’s condition permits
    6. Assemble equipment as student’s condition permits or utilize equipment in “GO BAG” (emergency travel bag)
    7. If ordered, place pulse oximeter on student’s finger, toe or ear lobe during and after the procedure
    8. Ensure the presence of another responsible adult, preferably another nurse if available, to assist with stabilizing the tracheostomy tube
    9. Put on gloves, goggles, and mask
    10. Have adult assisting with procedure put on gloves, goggles, and mask
    11. Suction the student’s tracheostomy tube (see Tracheal Suctioning-Clean Technique)
    12. If able, position the student supine on the floor with a shoulder roll to gently hyperextend the neck
    13. Open the new tracheostomy tube kit that is the same size as is currently in the stu­dent
      • Have the size smaller new tracheostomy tube readily available if needed
      • If new tube is not available, clean the old tube as possible
    14. Take care to not touch the curved part of the tracheostomy tube
    15. Lubricate the distal end of the new tracheostomy tube with water-based lubricant
    16. Return tracheostomy tube to the clean package that it was sealed in
      • If the tube has an obturator, be sure the obturator is in the tube
      • If the tube has an obturator, move it back and forth to be sure it will slide out easily
    17. Remove tracheostomy mask, artificial nose or ventilator connection, as necessary
    18. Give student two to four breaths with resuscitation bag
      • If unable to pass suction catheter, do not attempt to give breaths to a plugged trach. CHANGE THE TRACH TUBE
    19. Have adult assisting with procedure hold old tracheostomy tube in place by placing two fingers on the faceplate
    20. Assure tracheostomy tube cuff has been fully deflated, if applicable
      • Deflate the cuff per manufacturer’s instructions
    21. Remove or cut old tracheostomy ties
    22. With one hand remove the old tracheostomy tube and set it out of the way
    23. Insert new tube
      • If tube does not have an obturator, insert new tube at a right angle to the stoma, rotating it downward as it is inserted
      • If tube has an obturator, insert tube straight into stoma
        • Immediately remove the obturator and insert inner cannula (if trach tube has inner cannula)
          • Note many pediatric trach tubes do not have an inner cannula
      • Insertion of new tube should take no longer than 30 seconds
    24. Have adult assisting with the procedure hold the new tracheostomy tube in place
    25. If the tube has an obturator, remove the obturator with a motion that follows the curve of the tube
    26. Administer a minimum of three breaths with a manual resuscitator bag
    27. Secure the new tracheostomy tube in place by fastening the tracheostomy ties:
      • The ties should allow enough space for one pinky finger between ties and neck
    28. If this is a cuffed tracheostomy tube, inflate at this time per manufacturer’s in­structions
    29. Re-attach tracheostomy mask, artificial nose or ventilator connection, as necessary
    30. Position the student comfortably and observe to ensure he or she remains stable on their baseline level of supplemental or ventilator support (if any)
    31. Continue the respiratory assessment, using pulse oximetry, if available, until EMS has arrived
    32. Discard used equipment per school policy
    33. Remove gloves
    34. Wash hands
    35. Document assessment, intervention and outcomes in student’s healthcare record
    36. Notify parents/guardian and medical provider that student required a tracheostomy change procedure
    37. Replenish supplies in emergency travel bag

    If unable to replace tracheostomy tube:

    1. Reposition the student and re-attempt to place the tube
    2. If unsuccessful, attempt to place the smaller tube
    3. If unable to place a size smaller tube, assess child’s respiratory status to determine the need for rescue breathing
      • If rescue breathing is needed
        • Open the natural airway (the student’s mouth)
          • Be aware that some patients may not have a natural airway due to surgical procedures or anatomical abnormalities
        • Tape over the tracheal stoma
        • Give breaths using a manual resuscitation bag with a facemask
      • If rescue breathing is not needed and child’s respiratory status is stable
      • Continue to monitor respiratory status  

    References:

    Children’s Hospital St. Louis. (n.d.) Tracheostomy home care. Retrieved June 7, 2023, from https://media.bjc.org/sitelinks/tracheostomy/a001_changing_the_trach_tube_changing_the_trach_tube.html

    Children’s Mercy Kansas City. (2018). Office of evidence based practice (EBP) – Critically appraised topic: Tracheostomy emergency supplies. Retrieved June 8, 2023 from https://www.childrensmercy.org/contentassets/878a471901cd4e858cc27ae0d82f441e/trach-go-bag-cat.pdf 

    Children’s Mercy Kansas City. (n.d.). Tracheostomy care- Changing the tracheostomy tube. Retrieved June 8, 2023, from https://www.childrensmercy.org/siteassets/media/departments-and-clinics/otolaryngology/tracheostomy-care-changing-the-tracheostomy-tube.pdf

    Children’s Mercy Kansas City. (n.d.). Tracheostomy tube. Retrieved June 7, 2023, from https://www.childrensmercy.org/siteassets/media/departments-and-clinics/otolaryngology/tracheostomy-care-parent-card.pdf

    Children’s Wisconsin. (n.d.). 1-Person emergency trach change demonstration. . Retrieved June 8, 2023, from https://childrenswi.org/medical-care/tracheostomy-home-ventilator/educational-resources

    Children’s Wisconsin. (n.d.). One person trach change demonstration. . Retrieved June 8, 2023, from https://childrenswi.org/medical-care/tracheostomy-home-ventilator/educational-resources

    Children’s Wisconsin. (n.d.). Two person trach change demonstration. . Retrieved June 8, 2023, from https://childrenswi.org/medical-care/tracheostomy-home-ventilator/educational-resources

    Lawrence, P. R., Chambers, R., Faulkner, M. S., & Spratling, R. (2021). Evidence-based care of children with tracheostomies: Hospitalization to home care. Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses, 46(2), 83–86. https://doi.org/10.1097/RNJ.0000000000000254

    Pediatric Home Services. (2016). Emergency trach tube change (Cambio de emergencia de tubo traqueal). .Retrieved June 8, 2023, from https://www.pediatrichomeservice.com/tips-how-tos/emergency-trach-change/?play=1

    Porter, S.M., Page, D., Engholm. H., Somppi, C. (2019). Students supported by medical technology. In Selekman, J. (Ed.), School nursing, a comprehensive text (3rd ed.). (pp. 721-740). Philadelphia PA.: F.A. Davis Co.

    The StayWell Company, LLC.. (2021). Step-by-step: Changing a child’s tracheostomy. Retrieved June 8, 2023, from https://stlouischildrens.staywellsolutionsonline.com/MultimediaRoom/VideoLibrary/?e=0#player:138,A90943

    UC Davis Children’s Hospital, Olarewaju, A. (2019). Ear, nose, and throat (ENT) pediatric tracheostomy handbook. Retrieved June 7, 2023, from https://health.ucdavis.edu/media-resources/children/documents/patient-education-A-to-Z/peds-tracheostomy-handbook.pdf

    UpToDate. (2023). Patient education: Emergency care for infants and children with tracheostomy (the basics). Retrieved June 8, 2023, from https://www.uptodate.com/contents/emergency-care-for-infants-and-children-with-a-tracheostomy-the-basics?search=care%20of%20pediatric%20tracheostomy&source=search_result&selectedTitle=8~150&usage_type=default&display_rank=8

    Page last updated: February 28, 2025
    Page last reviewed: February 28, 2025

    The information and materials presented in this Website are intended for informational purposes only and are not designed to diagnose or treat a health problem or disease, or assist in diagnosis or treatment of the same.  The information is not intended to substitute for, supplement or replace clinical judgment.  If there are any concerns or questions about or relating to a nursing or medical procedure, contact the individual’s healthcare provider.  The information provided on this Website is not intended to be a substitute for medical orders and persons without the proper education, training, supervision and/or licensure should not perform the procedures.